No refuge from HIV

After the traumas of war and forced exile, HIV is an additional hardship for many refugees living in the small huts of clay and straw in a camp at Molangue, Central African Republic (CAR), near the border with the Democratic Republic of Congo (DRC).

According to the United Nations High Commission for Refugees (UNHCR), almost 20,000 refugees, mainly from Sudan, the DRC and Chad, fled war and violence in their countries and settled in camps and urban areas in the CAR. The camp at Molangue, about 150km east of the capital, Bangui, accommodates over 700 Congolese refugees.

The CAR became independent in 1960, only to be plagued by political instability and coups for over three decades. After democratic elections in 1993, Ange-Felix Patasse took power but was overthrown by current President Francois Bozize in 2003, who won a presidential election in May 2005.

It is one of the poorest countries in the world and among the ten poorest in Africa, with a population of less than four million, in which around 150,000 people have been internally displaced by years of bloody conflict and a continuous state of insecurity, especially in the north.

The consequences of such instability on the spread of HIV, particularly among populations of refugees and displaced persons, are unclear because there are no reliable statistics.

The Molangue health centre, run by the National Commission for Refugees (CNR), with financial and logistical support from UNHCR, lacks even the HIV testing equipment to measure levels of HIV infection in the camp and surrounding area.

"We observe clinical cases [among the patients], but we cannot say that they are cases of HIV/AIDS if we do not have a test to confirm that these patients are HIV positive," said Dr Daniel Djikoum, who runs the centre.

In 1997 Richard and Ruth [not their real names] were living in Kinshasa, capital of the Democratic Republic of Congo (DRC), then called Zaire, when rebellion against former president Joseph-Désiré Mobutu, also known as Mobutu Sese Seko, broke out. He had been working on the diamond mines, but Richard's links with Mobutu's sons, who were involved in mining, put them at risk and they returned to their hometown of Kisangani, in the northeast on the Congo River, but this was not far enough from Kinshasa. "They [rebels] started to look for me so we had to leave," said Richard, 42. "We left on foot, through the forest. We wanted to go to Nairobi [Kenya], but we lost our way and, one day, we arrived at a border - it was the Sudanese border." The couple and their children finally arrived in the Central African Republic (CAR) in August 1998 after several months of surviving on the charity of people they met along the way while travelling. After the arduous journey, two of the couple's five children died of malnutrition and respiratory problems soon after their arrival in Bangui. Without work or money, the family continued to rely on help from individuals and organisations, most notably the United Nations High Commission for Refugees (UNHCR), which regularly helped them with food. When Ruth became ill last March and didn't recover, the couple went to see the doctor at the National Commission for Refugees (CNR). "The doctor at the CNR advised us to be tested for HIV. We were both HIV positive," said Richard, as his wife wept softly at his side. "I am still in good shape but her condition is getting progressively worse. She needs ARVs [antiretrovirals], but there aren't any." Fewer than 3,000 of the more than 30,000 people in the CAR who need ARVs are receiving the life-prolonging drugs, and even fewer are refugees. UNHCR cannot provide the drugs, but offers the refugees psychological support and food. "We survive on the assistance we receive - even for food - but we cannot afford to send the children to school," said Richard. "And now that we are HIV positive, what will happen to our children? How will they live?" Their children have not been tested and do not know their parents are HIV positive. The couple hopes to find a way of accessing treatment without revealing their status and opening themselves to stigmatisation. Many of the 3,500 Congolese refugees still living in the CAR have been following the recent presidential elections in their country, hoping to be able to return if the situation stabilises. Voluntary repatriation operations, underway since the end of 2003, have made it possible for more than 3,200 Congolese to return home, but Richard and Ruth have little hope of joining them. "If I still had my house, I might be able to go back, but everything was broken. I lost all my possessions," he said. "And they are still looking for me. My father was killed in January because they couldn't find me. I am still in danger." The couple is also reluctant to stay in CAR, where there is no work, no HIV treatment, and above all, no future for their children. "I must continue for our children ... in the state in which my wife and I find ourselves, they must be helped," said Richard. "God wanted it to be so. We have not committed any crime."

According to UNAIDS, the HIV prevalence rate in the CAR is estimated at 10.7 percent, the highest in Central Africa and tenth highest in the world.

Fear of testing

The Molangue health centre treats camp residents as well as about 3,000 people from six surrounding villages. Djikouma refers patients displaying symptoms of AIDS-related illnesses to the nearest voluntary testing centre at Safa, about 10km from the camp while pregnant women are sent to Mbaïka, 30km away, where there are services available to prevent mother-to-child transmission of the virus.

Many of the patients referred for testing do not return. Djikouma said not only was ignorance about the advantages of testing widespread among the refugees, but stigma was also a deterrent - none of them spoke openly about their HIV-positive status.

"People believe that if they are known to be infected, they will be rejected and they don't want to be singled out," said Yabanga Baramoto, a refugee who came to the CAR in 1997 and is chairman of a camp committee set up to fight HIV/AIDS. "One of my friends at the camp had symptoms [of infection]. He went to Bangui to be tested and he was HIV positive. He did not return to Molangue. He died there [in Bangui]."

Baramoto said people's fears of HIV-related stigma and rejection were not misplaced: he and the other committee members have been stigmatised for organising HIV sensitisation meetings.

"People think that I am HIV positive because I am working on HIV sensitisation, and I have often been insulted," he said. "I was tested and the result was negative, but now when they accuse me of being HIV positive, I just accept it."

Despite their fear of rejection, more and more refugees are requesting HIV tests and according to Laurent Doka, CNR focal point for HIV/AIDS in Bangui, there are plans to set up testing services in refugee camps.

The sensitisation meetings have also created a greater demand for condoms, which usually cost 100 francs CFA (US$0.20) for three at the health centre.
"They are given free to the mothers who come to weigh their babies," said Ghislaine, a Congolese refugee with eight children. "If condoms are free, the women will use them to protect their bodies."

In 2004, the Global Fund to Fight AIDS, Tuberculosis and Malaria granted the CAR a five-year US$25 million grant to support its fight against HIV/AIDS, but according to the UN, only 2,860 of the 30,000 people who need ARV treatment are so far receiving the life-prolonging medication, of which very few are refugees.

"There is a long waiting list," said Nancy Adama Samory, of the HIV/AIDS unit at UNHCR. "For the moment one has to negotiate access [to the programme] for a refugee whenever there is an opportunity to do so."

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